Serra Medical Group will assure that all potential or actual CCS cases are referred to CCS and the Health Plan immediately. Will coordinate the care i.e. the follow-up on all CCS referrals and the facilitation of care between all involved parties, as needed.
Upon adequate diagnostic evidence that a Medi-Cal member under 21 years of age may have a CCS eligible condition, Serra shall refer the member to the local CCS office for determination of eligibility.
PROCEDURE:
- To timely refer all eligible patient with eligible condition to CCS.(within 24 hours of identification).
- To assure that a potential CCS case is a CCS designated Diagnosis that has not been referred to CCS or is awaiting a CCS determination to include the following criteria:
- A description of the CCS deferral process. To include the follow-up with CCS until group receives a final outcome of the CCS deferral (approval or denial) from CCS.
- All potential or actual CCS Cases are referred to CCS and the Health Plan immediately, not to exceed 1 business day from date of identification.
- The title of the person responsible for making the referral to CCS and the following up with CCS on the outcome (including process). (The HMO coordinator will process and follow-up until denied/approved).
- The title of the person responsible for notifying the health Plan Case Management of the CCS referral/case and the outcome. (The HME coordinator will inform the case manager of the referral to CCS).
- Evidence of CCS Education & Updates
- Serra Medical Group will provide evidence of CCS education and updates,
- Will provide evidence of list (s) of contracted and/or list non-contracted CCS paneled physicians
- And is accessible to the group’s practitioners/providers and the UM department.
- Serra Shall assure that Where a request is made for children’s preventive services by the Member, the Member’s parent(s) or guardian or through a referral from the local CHDP program, an appointment shall be made for the Member to be examined within two weeks of the request and reflected in the referral log.
- There must be documentation in the medical record noting that the PCP is aware of member’s CCS status, or that the PCP was the referring MD to CCS.
- Serra physicians must indicate in the medical record that the child is receiving routine preventive health services.
- Serra shall assure that at each non-emergency Primary Care encounter with Members under the age of twenty-one (21) years, the Member (if an emancipated minor) or the parent(s) or guardian of the Member shall be advised of the children’s preventive services due and available from PPG, if the Member has not received children’s preventive services in accordance with CHDP preventive standards for children of the Members’ age. Documentation shall be entered in the Member’s medical Record which shall indicate the receipt of children’s preventive services in accordance with the CHDP standards or proof of voluntary refusal of these services in the form of a signed statement by the Member (if an emancipated minor) or the parent(s) or guardian of the Member. If the responsible party refuses to sign this statement, the refusal shall be noted in the Member’s Medical record.
- In an emergency admission, Serra Medical Group or Serra’s network physicians shall be notified the next working day and inform the CCS program about the member.
- SCMC’s CCS policy/Procedure describes Serra’s process to identify and refer potential Case Management cases to the health plan and coordination between SCMC and the health plan CCS coordinator regarding CCS eligible cases.
- The Confidential Screening/billing Report form, PM 160-PHP, shall be used to report all children’s preventive services Encounters. Serra Medical Group submits completed forms to the appropriate Health Plan and to the local children’s preventive services program (local regional CHDP office) within thirty (30) calendar days of the end of each month for all encounters during that month.
- CCS Log shall include all factors:
- Member Name
- Date of Birth
- ID Number
- County
- Diagnosis/requested service
- Date request received
- Date referred to CCS
- ICCS Status
- Referral Status
- Denial / Carve Out Notification for CCS Eligible Members
- Letter will be issued appropriately and include instructions on how to file an appeal that is in compliance with all regulatory requirements.
- CCS Inpatient: When CCS approves admission, SCMC will issue a denial within 24 hours of the CCS decision.
- CCS Inpatient: Denied CCS admission, SCMC will adjudicate and approve per medical necessity guidelines or review with Medical Director and issue a CCS appeal when indicated.
- Designated Public Hospitals: Partial and full CCS eligible hospital stays will be directly billed to Medi-Cal FFS. SCMC will not be billed for part of the admission. The hospital will receive one payment for the entire stay based on the DRG for that stay.
- Private Hospital Admission: Partial and full CCS eligible hospital stays will be directly billed to Medi-Cal FFS. SCMC will not be billed for any part of the admission. The hospital will receive on payment for the entire stay based on the DRG for that stay.
- Services that are not covered by CCS, when necessary, there is documentation in the medical record that a specialty provider referral has been issued.
- When services are covered by CCS, there is a summary and/or documentation in the medical records by the PCP indicating the consult results have been reviewed or discussed with the CCS paneled physician.
- Serra physicians/healthcare providers must document evidence of transition planning from CCS to other programs for children who have reached age 19 and will continue to need services by the time they reach age 21. SCMC will assist patient to complete the “AGE OUT” form.
- Serra shall provide required notification to beneficiaries and representatives in accordance with the time frames set forth in Title 22, CCR, Sections 51014.1 and 53894. Such notice shall be deposited with the United States Postal Service in time for pick up no later than the third working day after the decision is made, not to exceed 14 calendar days from receipt of the original request for Medi-cal members.
- Letter must be approved by the Health Plan and DHS. The letter must include the following information.
- The action taken, the reason for the action taken and a citation of the specific UM Criteria, regulations or evidence of coverage supporting the action.
- Health Plans Complaint/Grievance Information
- State Fair Hearing Information
- Department of Managed Health Care(DMHC) Information e.g complaint process, TTY, Web Address, Independent Medical Review(IMR)
- The State’ s Toll Free Telephone Number & Address for obtaining information on Legal Service Organizations for representation.
- Translation or Written materials/ Translation Assistance.
